Costs to Physician Offices of Providing Medications to Medically Indigent Patients Via Pharmaceutical Manufacturer Prescription Assistance Programs

BACKGROUND: Prescription assistance programs (PAPs) are offered by pharmaceutical manufacturers to provide medications at no out-of-pocket cost to various categories of medically indigent patients. Some PAPs require only 1 application whereas others require as many as 4 applications per year per drug per patient, depending on the manufacturer's requirements. OBJECTIVES: to measure the costs incurred by a medical clinic that provides chronic prescription medications via PAPs. METHODS: this project was conducted in a free-standing, inner-city, Midwestern health clinic on the PAP application process for 1 representative drug for 32 pharmaceutical manufacturers that offered PAPs for drugs taken on a long-term basis for chronic conditions. Time and motion studies were conducted using a medical assistant with the greatest amount of PAP experience. Assessment of time-to-access and time-to-complete forms was performed outside of normal clinic business hours to avoid interruptions. Personnel time costs also included receipt and delivery of drug to the patient (drug distribution time), which were assessed during normal business hours for actual medications received for 10 patients and included the time required to notify the patient of the arrival of the drug and to dispense the medication to the patient. Supply costs for this PAP service included printing and copying costs. Submission costs associated with mailing or faxing the documents were determined and calculated using the price of materials only. Total application cost was calculated by adding the personnel time cost, supply cost, and submission cost. Annual PAP time was the time spent completing PAPs for 1 medication for 1 patient for 1 year. The time and resources required and the associated costs were aggregated separately for the pharmaceutical manufacturers that required 1, 2, or 4 applications per drug per patient per year. RESULTS: The total average application cost for all 32 companies was $25.18 [SD, $17.23]. Personnel time costs accounted for half or more of the total application cost, regardless of submission mode. The time to complete the form for any PAP was 0:06:20 [SD, 0:05:03] minutes with a range from 0:03:01 to 0:34:22 minutes. Printing costs were $0.20 [SD, $0.10] and copying costs were $1.96 [SD, $0.21]. Average supply costs were $2.16 [SD, $0.23]. Faxing versus mailing PAPs saved $17.90 per application. total annual clinic cost to assist patients in obtaining drugs through a PAP ranged from $10.42 per patient for a drug that requires 1 application per year (15 manufacturers, 47%) to $46.30 per patient for a drug in a PAP that requires 4 (re)applications per year (12 manufacturers, 38%). PAPs transmitted by mail required 0:49:18 [SD, 0:32:18] minutes, approximately 0:25:00 [SD, 0:21:00] minutes more than by fax (0:24:13 [SD, 0:11:32] minutes) or by Internet submissions (0:28:20 minutes), respectively. CONCLUSIONS: the number of PAP applications required per patient per medication annually has the greatest impact on clinic time and financial resources. Application submission method also influences the overall costs of providing this service in the clinical setting. Medical clinics should base their decision to provide a PAP application service to patients on the time and costs associated over the course of 1 year and not on the 1-time application cost.

" C hange is required so that alternative methods of providing and financing health carew ill extend coverage to low-income groups with high health caren eeds." 1 Despite this proclamation, written 20 years ago by Dr.H .P.E kern, the inability of the low-income or medically indigent population to pay for prescription drugs in the United States continues to be ab arrier to receiving them. According to the Centers for Medicare&M edicaid Services, spending on prescription drugs increased 5.8% in 2005. 2 As health carecosts increase, and in particular,prescription drug costs, the disparities between the manufacturers' prices and the consumers' ability to pay for treatment will widen.
Medically indigent patients often do not meet requirements for Medicaid eligibility but areunable to affordprivate insurance coverage. In 2005, af amily of 4w ith an annual household income at or below $19,350 was considered to be living below the poverty level. 3,4 However,$ 14,512 (75% of federal poverty level) was the cutofff or Medicaid eligibility. 3,4 It is likely that this household could not affordp rivate health insurance with prescription drug coverage, and it would fall into this medically indigent category.
BACKgrOund: Prescription assistance programs (PAPs) areoffered by pharmaceutical manufacturers to provide medications at no out-of-pocket cost to various categories of medically indigent patients. some PAPs require only 1application whereas others requireasmany as 4applications per year per drug per patient, depending on the manufacturer's requirements.
OBjeCtIVe: to measurethe costs incurred by amedical clinic that provides chronic prescription medications via PAPs.
MethOds: this project wasconducted in afree-standing,inner-city, Midwesternhealth clinic on the PAPapplication process for 1representative drug for 32 pharmaceutical manufacturers that offered PAPs for drugs taken on along-termbasis for chronic conditions. time and motion studies wereconducted using amedical assistant with the greatest amount of PAP experience.Assessment of time-to-access and time-to-complete forms was performed outside of normal clinic business hours to avoid interruptions. Personnel time costs also included receipt and deliveryofdrug to the patient (drug distribution time), whichwereassessed during normal business hours for actual medications received for 10 patients and included the time required to notify the patient of the arrival of the drug and to dispense the medication to the patient. supply costs for this PAPservice included printing and copying costs. submission costs associated with mailing or faxing the documents weredetermined and calculated using the price of materials only.total application cost wascalculated by adding the personnel time cost, supply cost, and submission cost. Annual PAPtime wasthe time spent completing PAPs for 1medication for 1patient for 1year.the time and resources required and the associated costs wereaggregated separately for the pharmaceutical manufacturers that required 1, 2, or 4applications per drug per patient per year. results: the total average application cost for all 32 companies was$25.18 [sd,$17.23 COnClusIOn: the number of PAPapplications required per patient per medication annually has the greatest impact on clinic time and financial resources. Application submission method also influences the overall costs of providing this service in the clinical setting.Medical clinics should base their decision to provide aPAP application service to patients on the time and costs associated over the course of 1year and not on the 1-time application cost.

Costs to Physician Offices of Providing Medications to Medically Indigent Patients ViaPharmaceutical Manufacturer Prescription Assistance Programs
Knowing the status of health carecoverage for patients is vital for providers to better serve their patients' medical needs. 5,6 The benefits of providing prescription drugs to medically indigent patients who areo therwise unable to pay for them arew ell documented. 7-10 By complying with proper treatment regimens, patients arel ess likely to develop secondaryd isease associated with improper pharmaceutical compliance. [11][12][13] Pharmaceutical company prescription assistance programs (PAPs) ared esigned to provide access to medications for those who areu ninsured and unable to pay for their medications. Strum and colleagues found that offering the manufacturer PAPs ervice to their patients with diabetes reduced lowdensity lipoprotein cholesterol and hemoglobin A1C values significantly. 14 Additionally,p atients could have access to more medications after they weree nrolled in PAPs than when they werep aying for their prescriptions themselves. Providing free or low-cost prescription drugs helps to improve medication adherence and reduces hospitalization rates as well as emergency room visits. [11][12][13][14] The inability to pay for prescription drugs causes prematureloss of life, loss of potential work time, and decreased quality of life. 15 Research has shown that health carei nstitutions, in addition to improving patient outcomes, can reduce bad debt claims resulting from uncompensated prescriptions by implementing their own PAPs. 16 The cost of caring for the medically uninsured, indigent population usually falls on the local hospitals that treat these patients as an ambulatoryo utpatient service. 17 Without access to needed medications, disease often progresses and emergency therapy is often needed to avoid acute complications or death. 13 Therefore, physicians and medical groups that choose to forgo PAPparticipation because of administrative cost and/or time concerns may ultimately bear financial responsibility for these patients. 18 In 2004, PAPa ccess expanded to moret han 22 million prescriptions, representing as much as $4 billion in medications for patients. 19 Despite these numbers, PAPs areoften underused because of the complex application process. 10 In fact, even using the heavily promoted www.pparx.orgW eb site, individuals are still instructed to go through their doctor' so ffice to complete the application process: "Herea re the assistance programs that you have selected. Some of the applications requirethat you contact the company,others need to be filled out and signed by your doctor. Youcan print the applications and details sheets for those programs that don'thave applications available now or you can use our online application wizardtofill out all of the 'online available' applications at once. Youcan then print them and deliver them to your doctor." 20 Most medically indigent patients areu nable to participate in PAPs without assistance from health carep rofessionals, many of whom lack time, training, or incentive. 13 Some institutions have assigned personnel and established specific protocols to assist patients and providers in completing and submitting the PAPa pplication forms and supporting documentation. 7,10,[14][15]18,[21][22][23][24][25][26][27][28][29][30] This processing requires several steps, including completing the form in its entirety,p roviding an original signatureb yt he prescriber,attaching the prescription and any required financial information, submitting this information to the manufacturer, and often requiring receipt of the medication at the prescriber' s office between 2t o8w eeks following submission of the PAP form. Additionally,t he majority of PAPs provide a3 -month supply of medication at one time and requireanew application for each subsequent quarterly supply; hence, 4a pplication submissions per year.
To date, thereh ave been no published data describing personnel time and material costs incurred by organizations providing this service to patients. The objective of this study was to measuret he costs incurred by am edical clinic that provides chronic prescription medications via PAPs.

■■ Methods
This project was conducted in af ree-standing, inner-city, Midwesternh ealth clinic serving moret han 13,000 medically indigent patients with moret han 47,500 patient encounters in 2005-2006. 31 The Kansas City Free Health Clinic has extensive experience using PAPs, having processed moret han 3,250 PAPa pplications annually since 2001. 32 At otal of 143 unique medications from 39 pharmaceutical companies werei nitially considered for inclusion. Drug inclusion criteria wereb oth approved by the U.S. Food and Drug Administration for use in achronic medical condition that requires ongoing use (refills) to appropriately treat the condition and obtainable via aP AP.
In the early stages of data collection, it was determined that each pharmaceutical company had au nique application form but identical PAPr equirements for different drugs within each company.O nt he basis of this finding, 1r epresentative drug from each company was used to generate project data. PAP forms varya mong pharmaceutical manufacturers with respect to (1) qualification standards, (2) submission criteria, and (3) supporting documentation required. Therefore, the unique PAPapplication requirements from each company wereanalyzed individually using 1drug from each manufacturer.Additionally, it is imperative to note that the necessaryc omponents to complete the application, the structurea nd organization of the application, and the number of signatures varyb ye ach manufacturer,m aking it vital to assess the time necessaryt o complete each unique manufacturer' sapplication. The time and resources required and the associated costs werea ggregated separately for the pharmaceutical manufacturers that required 1, 2, or 4applications per drug per patient per year.
Time and motion studies wereconducted based on previously published methodologies. [33][34][35] Medical assistants werea ssigned to complete PAPa pplications because they were( 1) capable of completing the forms and (2) determined to have the lowest annual payroll cost per full-time equivalent salary. 36 Only the medical assistant with the greatest amount of PAPe xperience was used for the time and motion study to eliminate the potential confounder of unfamiliarity with the PAPs. The study of time-to-access and time-to-complete forms was performed outside of normal clinic business hours. This method was used to avoid counting time costs associated with interruptions in workflow during ac ustomaryb usiness day.E ach application was completed 3times by the experienced medical assistant and recorded by one of the authors (Mangum).
All applications werea ccessed via 1o f2I nternet search engines-the Partnership for Prescription Assistance (www. pparx.org) or an onprofit organization (www.needymeds.com). These 2s earch engines wereu sed because of their extensive inventoryofP AP forms.
Total application cost was calculated by adding the personnel time cost, supply cost, and submission cost that areo utlined and defined in Table 1. Personnel time cost from receipt of drug to deliveryt ot he patient (drug distribution time) was assessed by time and motion observation performed by 1ofthe authors (Mangum) of the actual medications received for 10 patients. This time measurement was the only component of personnel cost that was completed during normal clinic hours (drugs are not received on weekends). It is the medical clinic' spolicy to have all drugs delivered to the clinic and not directly to the patient because of the variable quality of housing situations among clinic patients and uncertainty regarding home receipt and accountability for the drugs. Once am edication was received, personnel, under the supervision of ap hysician, record, label, and storethe drug at the clinic.
The oversight by the physician is an added safety check and one that is required by the clinic. Because the time from PAP application submission to receipt of medication may be as long as 8weeks, this verification is designed to ensurenochange in medication therapy has occurred since the request was forwarded to the manufacturer.R ealizing that the medication is checked for accuracy by the drug manufacturer beforeshipping and that this added step in our clinic may be unique, we did not include the physician' st ime in the analysis. The other components of the drug distribution time portion of total personnel cost include the time required to notify the patient of the arrival of the drugs and the time to dispense the medication to the patient. This part of the PAPprocess is the same for all medications received and thereforedoes not differ among the PAPs.
Personnel time cost also included the time to access and complete forms. The information necessaryt oc omplete the forms was categorized into 5g eneral sections: (1) patient information, (2) health careprovider information, (3) prescription  (Table 2). Supply cost for this PAPservice included printing and copying costs. The same computer,p rinter,c opier,f ax, and charting system wereu sed for all PAPs to ensuret hat the mechanical speed of different machines was not af actor in the final results (Table 1).
Submission cost associated with mailing 37 or faxing the documents was determined and calculated using only the price of materials involved in submitting the documentation and did not include personnel time cost ( Table 1).
As part of this clinic' ss ubmission process, personnel make 2c opies of the application and all supporting documents. One set of copies is given to the patient for his/her records, while the other set is placed in the patient' sm edical record. If the application is mailed, the original application and supporting documents aresent. Alternatively,ifthe application is faxed, the original documents ared estroyed once successful transmission of the fax has occurred. For purposes of this study,t he actual documents weren ot sent to the pharmaceutical company because patient information was fictitious. The times required by the pharmaceutical company to process the application, fill the prescription, and deliver the prescription wereo utside the scope of this study.
Annual PAPt ime was the time spent completing PAPs for 1medication for 1patient for 1year.T welve of the 32 companies (38%) required an ew application with each prescription order for 3m onths (meaning 4P AP forms per patient per year per medication), while 5m anufacturer PAPs (16%) required 2application forms per patient per year,and 15 manufacturers (47%) required only 1application each year (Table 3).
Time measurements werecollected in an hour:minute:second format and depicted as such. Cost components wered escribed in U.S. dollars and cents. Means and standardd eviations weret abulated for all components. Differences in time and costs associated with submission methods and the number of applications required per year werea nalyzed by multivariate analysis of variance, followed by univariate analyses and post hoc testing, as appropriate. This project was approved by the Kansas City University of Medicine and Biosciences and the University of Missouri-Kansas City Institutional Review Boards.

■■ Results
Thirty-nine pharmaceutical companies wereo riginally considered for analysis. Data analysis was conducted on the 32 pharmaceutical companies that met the stated inclusion criteria. Total application cost is displayed in Figure1  incurred by mailing compared with faxing the application was ah igher proportion of the total application cost. Faxing versus mailing PAPs saved $17.90 dollars per application.
The average annual PAPtime and costs aredisplayed in Figure2. The annual PAPt ime was directly affected by the number of applications required per year for each medication. As can be seen in Figure2,the increase in annual PAPtime associated with multiple PAPapplications for the same drug for the same patient had ad irectly proportional but not linear effect on annual PAP time and cost. Annual PAPt ime was also affected by method of submission. Mail submission (n =2 7) required an average of 0:49:18 [SD,0:32:18] minutes, approximately 0:25:00 and 0:21:00 minutes moret han fax (n =4 ,0 :24:13 [SD, 0:11:32] minutes) or Internet submissions (n =1 ,0 :28:20 minutes), respectively.P ersonnel time associated with 4a pplications accounted for 48.1% to 52.4% of total annual cost per drug per patient and varied by the submission method (Figure2).

■■ Discussion
Using office personnel to provide medications to patients via PAPs is ac ostly endeavor.O ver 4y ears beginning in 2001, our medical clinic spent $327,240, or $81,835 annually,f or this service. 32 Not surprisingly,P APs that required moret han 1a pplication per patient per year and had to be mailed were the most costly.Mailed applications had an average total cost of nearly 3times the cost of applications submitted by fax, $28.03 versus $10.13. PAPs that required 4a pplications per drug per patient per year had an annual cost that was morethan 4times the cost ($46.30) of amanufacturer that required 1application per year ($10.42).
It is important to note that aP AP that requires 4applications per year does not simply requirec ompleting the "once-annual" application and submitting it 4t imes. Instead, it involves

FIGURE 1
Total Application Cost Per Application by Method of Submission*  (Table 2) and repeating the entirep rocess 3m oret imes. Each PAPr equires ad ifferent amount of information necessaryt oc omplete the application; hence, each manufacturer' sa pplication is unique. One cannot simply take the cost necessaryt oc omplete the application for ac ompany that requires only ao nce-annual submission and multiply it by the number of each reapplication for another company and expect to appropriately judge the cost of time to complete the application. These estimated PAPc osts werem inimized through the use of lower-payroll personnel, time of observation (e.g., outside of normal clinic hours for some of the observations), and personnel familiarity with the various PAPprocess and information requirements. Support for the personnel time and cost findings for this study can be found in the literature. Previous research conducted by Richardson and Basskin 30 in asurvey of 118 safety-net providers, of which 52 wereinaclinic setting, illustrated that respondents reported that paper applications required an average of 1.1 hours, 36% morethan the average 0.81 hours in the present study,a nd 0.8 hours per electronic submission, twice the 0.4 hours found in the present study.Sarrafizadeh and colleagues 24 estimated the personnel time in aprivate ambulatorycareclinic and found that 1m edication order for aP AP used 1h our of a pharmacist' st ime. Coleman and associates 35 conducted as tudy in an inpatient setting and reported average personnel time, tracking time via at ime log, of 2.25 hours per day over 129 program working days to process 96 PAPa pplications, which resulted in approximately 3hours per application.
Our study directly measured the time necessaryfor personnel to complete applications, whereas these previous studies used only estimates of personnel time. Another potential for the variance in PAPtime requirements across studies may be explained in part by our methods, in that the time and motion studies for completing the applications werec onducted outside of normal clinic hours. Weiner and colleagues reported 6-month operation costs of $110,537 for abroad-scope patient assistance program in 1999-2000 that included aP AP service, and drug cost savings of $237,985 that included aP AP cost offset in free goods of $31,028 (13%). 10 This study included overhead, higher-salaried personnel without breakdown by type of personnel, and did not report the volume of PAPa pplications. This broader-scope patient assistance program to obtain lower-cost medications had an operating cost, if annualized, of $958 per patient, delivering about $2,060 per year in drug cost savings or asavings-to-cost ratio of about 2.2-to-1.
Meaningful comparison of our findings and prior studies were made difficult as ar esult of methodological differences. Other programs, for instance, charge af ee for each prescription filled in the PAPtooffset expenses for the program. 30 Moreimportant, beforet he present study,p hysicians wereu nable to use these data to predict the feasibility of providing this service in their own setting because ap rojected cost per PAPh ad not been determined. As an example of the value of the present study,i t is possible to estimate aprojected increase of 206% in personnel costs compared with our results if ar egistered nurse is used rather than amedical assistant. 36 It should be noted that all of the companies that participate in PAPs areb rand-name drug companies. In community practice, therei so ften at herapeutically equivalent generic alternative in the same drug class as the prescribed medication. In theory, prescribing the generically available alternative in place of the  brand-name drug would lower the overall health carec ost for the patient. 38 However,s ome of these patients who use PAP programs have difficulty even paying for generic drugs, which would lead to noncompliance, disease progression, and/or increased overall health carec osts. This is why the prescribing of brand-name drugs and the use of PAPs aree ssential for the careofsome clinic patients. Therea re some alternatives to providing PAPs in medical offices. Tw oInternet sites (www.pparx.organd www.rxassist.org) provide eligibility information and downloadable prescription assistance applications. These sites areefficient to use in locating forms and instructions compared with the alternative method of trying to find PAPinformation on each individual pharmaceutical Webs ite. The features of these Webs ites improve the initial access to the manufacturer' sa pplication and provide accurate manufacturer contact information but do not eliminate the majority of time and costs that must be assumed by medical offices to provide PAPservices for patients.
Outsourcing assistance for patients to obtain drugs through PAPs is another option, since not everym edical practice can affordt op rovide the necessaryp ersonnel and materials. As such, others have reported savings of $27,000 per year by using an outside source to assist patients in completing PAPs. 10 Locally,c ommunity health centers and the United Wayh ave developed programs to improve access to medicines for the medically indigent. 39 Physicians in communities with these resources available can provide contact information and patient brochures about these services in their offices. In many cases, these organizations already have the established clerical support in place and requirem inimal charge, if any,t op rovide application assistance. Internet groups such as The Medicine Program and Medicine Bridge offer patients help in obtaining and completing PAPs, albeit for af ee. 40,41 Morer ecently,P atient Assistance Program Solution (www.paprx.com) has begun offering asoftwarepackage to assist with the PAPprocess. 42 No formal comparison has been conducted, to date, among the various assistance programs.
Recently,a nother local metropolitan free health clinic incorporated the use of ac omputerized program to assist with the PAPp rocess. This clinic is staffed completely by volunteers and open only 1n ight each week. In 2005, the clinic served moret han 350 patients in 26 different zip codes. 43 Since the clinic opened in 2000, morethan 6,000 patient visits and more than $1.3 million in free medications have been donated by pharmaceutical PAPs, with moret han 1,900 PAPa pplications processed in 2006. 44 This clinic serves as imilar population to the one described in the present study,a nd it is possible to estimate from our data the time that might be saved by using a computerized program for the PAPp rocess. From our data in Table 2and assuming that the supply and submission cost would be similar between the 2c linics because the computer system did not change the submission modalities or the additional forms necessarytoprocess PAPs forms, the time to complete an application is reduced to 0:02:13 minutes compared with more than 0:06:00 minutes with manual writing. 45 This time savings is offset by the upfront personnel time that is required to input all the data for each patient into the computer system and to keep it updated, as well as the cost of the softwareand annual renewal fees. While all the staffa re volunteers in that comparison free health clinic so therei sn op ersonnel time cost, this alternative method of completing PAPs may provide additional information to clinics evaluating the feasibility of providing patients with assistance in using PAPs.
"Development of a' universal' PAPa pplication process would greatly benefit patients and health careproviders as well as reduce personnel time required to complete individual applications," according to Chishom and DiPiro. 13 Often the reasoning behind making the process as complex as it is lies in the pharmaceutical companies' requirement to determine income eligibility and if alternative sources of funding area vailable to the patient. However,t he need to verify eligibility moret han once ay ear seems questionable. Nevertheless, having the forms available to patients in am oreu niversal, standardized format and without requiring prescriber information other than the prescription itself would solve much of the problems and the professional time required.
Requiring the prescriber' ss ignatureo nt he individual application to verify the information provided on the application and certify that thereisnofalsification of data seems unnecessarily burdensome. This requires time of the clinic staff and prescriber as well as the patient to have the prescriber give an additional signatureifthe clinic does not offer aP AP service. This requirement of as econd signatureb yt he prescriber on the PAPa pplication makes it impossible for ap atient to take the prescription from the prescriber,d ownload the form from ap ublic place, and submit the PAPd irectly.R ather,t he patient must make asecond trip to the prescriber for his or her signature to certify that the PAPform submitted by the patient is truthful and complete.
If the application is approved by the pharmaceutical manufacturer and the medication is mailed, the majority of manufacturers mail the medication directly to the prescriber. This requires that someone at the medical clinic accept the mailed prescription and contact the patient. Then the indigent patient must again incur at ravel expense to pick up the medication. While the cost of medications provided by pharmaceutical manufacturers helps to control chronic illness and reduce acute careexpenditures, the cost to providers, clinic staff, and patients who use the PAPs reduces the total cost savings from PAPs.

Limitations
The first limitation is that the time and motion study was performed outside of normal business hours to (1) avoid interference with clinic operations and (2) isolate the time

Costs to Physician Offices of Providing Medications to Medically Indigent Patients
ViaPharmaceutical Manufacturer Prescription Assistance Programs actually necessaryf or performing the tasks related to fulfilling the requirements for PAPa pplication, receipt, and distribution of drugs to patients. This method may underestimate the actual time required by clinic personnel to complete the work required by PAPf acilitation for patients. Second, the staffm ember with the most experience in completing and submitting particular PAPs was observed, which would tend to underestimate the average time required if several staffm embers rather than a specific, experienced staffmember wereassigned responsibility for PAPs. Third, the medical assistant with experience in PAP applications had the lowest payroll cost among the professional staffinthe clinic, and thereforeour cost estimates would tend to be lower than would other medical clinics that use higher-cost professionals to provide PAPservices. Fourth, the time and motion observations werenot performed by experts and included observation of only 1medical assistant and should thereforeb ec onsidered estimates. Fifth, the reliability of the time estimates is affected by the small number of observations-3 observations for the time estimates made in off-hours and at otal of 10 observations for direct distribution time.

■■ Conclusion
The number of PAPa pplications required per patient per medication per year has the greatest impact on clinic time and financial resources. The application submission method (i.e., mail, fax, or Internet) also influences the overall costs of providing this service in the clinic setting. Because of the variable number of PAPa pplications required by different drug manufacturers, medical clinics should base their decision to provide assistance with PAPa pplications on the time and associated costs over the course of 1year and not on the 1-time application cost.